Medicare Compliance & Reimbursement

Fall implementation looms for new codes.

Changes in the way Medicare classifies and pays for power mobility devices (PMDs) are nearly ready to roll, but stakeholders are nervous: The feds have yet to say how much they'll pay for PMD products come Oct. 1.

After two false starts, the Centers for Medicare & Medicaid Services (CMS) has released preliminary information on a revised set of new codes for PMDs--a code set that seems destined to stick, industry insiders say. The new set of 64 codes updates the existing set of just four Healthcare Common Procedure Coding System (HCPCS) codes for power wheelchairs.
 
CMS has set an implementation date of Oct. 1, 2006 for the new code set.

Currently, just one HCPCS code is used to specify "power operated vehicle" (E1230, power operated vehicle, three- or four-wheeled non-highway). When listing E1230, suppliers must "specify brand name and model number," but no specific codes have been available to categorize the increasing number of products available.

"Innovation in the field created a need to expand both the number of categories and the number of codes," CMS explains.

Updated file: On June 9, the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) released guidelines elaborating on CMS' June 2 code release.

The SADMERC's "narrative information includes definitions, performance requirements, and a list of items to be included in the basic equipment package," explains Tara Gentile of Permobil USA Inc., a PMD manufacturer based in Lebanon, TN.

The code structure includes six power wheelchair groups and two power operated vehicle groups. Each grouping is further divided by performance, patient weight capacity and powered seating system capability.

Watch For Fee Schedule

"We expect the policy and pricing updates to follow sometime this summer," says Gentile, who served on the technical expert panel that worked with CMS to develop and refine the code set.

Manufacturers previously have expressed concern over CMS' plans to use a "gap-filling" methodology to devise the fee schedule that will link to the new codes.

That methodology could result in prices that fail to reflect manufacturers' current costs, contend industry groups including the National Coalition for Assistive Rehab and Technology (NCART).

CMS should recognize that the historic trend in power wheelchair prices is not represented by the CPI-U component under the gap filling methodology, noted the Washington, DC-based NCART in an issue brief released last fall.

Concern:  Suppressing prices for PMDs in the forthcoming fee schedule could be especially damaging to the industry, given the move toward competitive bidding for durable medical equipment, cautions Erik Sokol, director of the Power Mobility Coalition in Washington, DC.

The SADMERC notes this set of codes is an interim step to allow implementation, and that a set of "K" codes to be used for billing will be developed by the Alpha Numeric Work Group before Oct. 1.

Note Essential Next Steps

Implementing the new codes and testing standards will proceed as follows, according to CMS:

1. The SADMERC will apply testing results already submitted to place wheelchairs in the appropriate new code based on the results of these test.

2. The new codes will take effect for claims for items furnished on or after Oct. 1, 2006. The current codes will remain valid for items furnished before Oct. 1, 2006.

3. Fee schedules for the codes are expected to be published as part of the October 2006 DMEPOS update.

4. Suppliers will have until Aug. 1, 2007 to have their wheelchairs retested by an independent testing laboratory, according to the testing requirements.

5. Fee-schedule amounts will be revised, as appropriate, to reflect any changes in product classification under the codes as a result of the retesting and will be implemented on Jan. 1, 2008.

Note: To access the June 9 coding guidelines, go to www.palmettogba.com/index.html and click on "SADMERC" at the bottom of the page.